Aetna Claims Process Guide

Do you ever have trouble with the Aetna appeals process? See below for a helpful guide on how to do it.

The EOC provides the most comprehensive information about appeals. Information can be found briefly in Chapter 2, and more in Chapter 9. The information will depend on the plan.

For a quick find on desktop, use the keyboard shortcut of CTRL+F while in the EOC to open a text search, and type “appeals” to search for the word.

To find the EOC, go to www.aetnamedicare.com/H5521-081 and scroll down. You'll find the EOC under the "Your Plan Documents" section.

The member may want to proceed with the appeal process online - this is the best option. It leaves a paper trail with written responses from Aetna so that the issue can be easily tracked and resolved quickly.  

Members can also fax the completed paper reimbursement form and receipts if they choose, but make sure any documentation is identified with the member ID on each separate page. The fax number is 1-724-741-4953.

Here’s how to proceed online:

Brokers are allowed to submit on behalf of the member.

1. Go to www.Aetnamedicare.com and click on Members.
2. A menu will open and on the left side under “Manage my plan” - click on “appeals and grievances.”
3. Scroll down slightly and choose the pull down arrow for “Medical Care benefits or coverage” or other selection that is appropriate.
4. Click on “request a medical appeal”.  Two purple bars will appear.
5. Click on “Submit a claim denial appeal online.”  The digital form will open.  There is a comments box for important messaging.  
6. Complete the form and be as specific as possible in the comments box. Try to be short and to the point.  
   • The facts are all they need! Here's a good example: “Member expected Aetna to pay $xxx.xx but they only paid $xx.xx.  Please review”.
   • Always provide the Date of service, the specific amount the member expected Aetna to pay, and the name of the Provider.
   • If it is a dentist, use the dentist’s actual name and not the name of the office.

If a first appeal is denied, member can appeal up to 3 times if they still disagree with the outcome.

Each time an appeal is submitted it rises to another level of appeal management.